Nursing activities score

[Inter-rater concordance of the "Nursing Activities Score" in intensive care]

OBJECTIVE

To evaluate inter-rater concordance in the valuation of the "Nursing Activities Score".

METHOD

Cross-sectional descriptive study conducted from December 2012 until June 2013 in a general intensive care unit with twelve beds. Three evaluator nurses, simultaneously and independently, through the patient daily charts, scored the nursing workload using Nursing Activities Score scale in all patients admitted over 18 years old.

RESULTS

Three hundreds and thirty-nine records were collected. The intra-class correlation coefficient (ICC) between evaluators was 0.92 (0.89-0.94). A perfect concordance was obtained in 39.1% of the items, with 52.2% having a high, and 8.7% having lower concordance, corresponding to two of the items with multiple scoring options. Significant differences between two of the evaluators (P=.049) were found.

CONCLUSIONS

Although the inter-rater concordance was high, more accurate records are needed to reduce the variability of the items with multiple options and to allow more accuracy in the interpretation and measurement of the data regarding nursing workload.

[Analysis of the workload and the use of the nursing resources in an intensive care unit]

OBJECTIVE

To evaluate and assess the nursing workload (NW) scales by means of three scales and to determine the theoretical and real nurse/patient relationship in a polyvalent ICU.

METHODOLOGY

Cross-sectional descriptive study between July 2012 and June 2013 in patients over 18 years old, for which 3 nurses quantified, in randomized days, the NW by the Nursing Activities Score (NAS), Nine Equivalents Manpower Score (NEMS) and Valoración de Cargas de Trabajo y Tiempos de Enfermería (VACTE). Efficiency parameters of nursing resources were calculated: "work utilization ratio" (WUR), "level of care" operative (LOCop) and planned (LOCp). Data on demographics, length of stay and number of nurses were collected.

RESULTS

720 records were collected. The mean age was 64 (13.6) years. 73% were male and the median of length of stay was 3 (1-12) days. 60% were admitted for medical causes. The average total score was: NAS: 696.8 (111.6), NEMS: 311.8 (55.3) and VACTE: 4,978 (897.7). The required number of nurses according to NAS was 7 and 6,7 according to NEMS and VACTE. The actual average was 5.5. On all 3 scales the WUR was >1 and LOCop was 1.6 pacients/nurse. The LOCp was 2 patients/nurse.

CONCLUSION

Assessing NW allows to know the reality of each unit. According to the scales and efficiency parameters of the nursing resources used, there is a shortage of nurses in relation to the work generated. NAS reflects more parameters of NW.

Nursing workload in public and private intensive care units

Objective

This study sought to compare patients at public and private intensive care units according to the nursing workload and interventions provided.

Methods

This retrospective, comparative cohort study included 600 patients admitted to 4 intensive care units in São Paulo. The nursing workload and interventions were assessed using the Nursing Activities Score during the first and last 24 hours of the patient's stay at the intensive care unit. Pearson's chi-square test, Fisher's exact test, the Mann-Whitney test, and Student's t test were used to compare the patient groups.

Results

The average Nursing Activities Score upon admission to the intensive care unit was 61.9, with a score of 52.8 upon discharge. Significant differences were found among the patients at public and private intensive care units relative to the average Nursing Activities Score upon admission, as well as for 12 out of 23 nursing interventions performed during the first 24 hours of stay at the intensive care units. The patients at the public intensive care units exhibited a higher average score and overall more frequent nursing interventions, with the exception of those involved in the "care of drains", "mobilization and positioning", and "intravenous hyperalimentation". The groups also differed with regard to the evolution of the Nursing Activities Score among the total case series as well as the groups of survivors from the time of admission to discharge from the intensive care unit.

Conclusion

Patients admitted to public and private intensive care units exhibit differences in their nursing care demands, which may help managers with nursing manpower planning.

[Validating the Spanish version of the Nursing Activities Score]

INTRODUCTION

Validating workload scores ensures that they are appropriate for the purpose for which they were developed.

OBJECTIVE

To validate the Nursing Activities Score (NAS) Spanish version.

METHODOLOGY

Observational and prospective study. 1,045 patients who were admitted to a medical-surgical unit and a serious burns unit in 2006 were included. The nurse in charge assessed patient workloads by Nine Equivalent of Nursing Manpower use Score and NAS. To assess the internal consistency of the measurements of NAS, item-test correlations, Cronbach's α and Cronbach's α corrected by omitting each of the items were calculated. The intraobserver and interobserver reliability were assessed with the intraclass correlation coefficient by viewing recordings and Kappa (interobserver reliability) was estimated. For the analysis of internal validity, a factorial principal components analysis was performed. Convergent validity was assessed using the Spearman correlation coefficient values obtained from the Nine Equivalent of Nursing Manpower use Score and Spanish-NAS scales.

RESULTS

For internal consistency, 164 questionnaires were analysed and a Cronbach's α of 0.373 was calculated. The intraclass correlation coefficient for intraobserver reliability estimate was 0.837 (95% IC: 0.466-0.950) and 0.662 (95% IC: 0.033-0.882) for interobserver reliability. The estimated kappa was 0.371. For internal validity, exploratory factor analysis showed that the first item explained 58.9% of the variance of the questionnaire. For convergent validity 1006 questionnaires were included and a Spearman correlation coefficient of 0.746 was observed.

CONCLUSIONS

The psychometric properties of Spanish-NAS are acceptable.

Gender differences in outcome and use of resources do exist in Swedish intensive care, but to no advantage for women of premenopausal age

INTRODUCTION

Preclinical data indicate that oestrogen appears to play a beneficial role in the pathophysiology of and recovery from critical illness. In few previous epidemiologic studies, however, have researchers analysed premenopausal women as a separate group when addressing potential gender differences in critical care outcome. Our aim was to see if women of premenopausal age have a better outcome following critical care and to investigate the association between gender and use of intensive care unit (ICU) resources.

METHODS

On the basis of our analysis of 127,254 consecutive Simplified Acute Physiology Score III-scored Swedish Intensive Care Registry ICU admissions from 2008 through 2012, we determined the risk-adjusted 30-day mortality, accumulated nurse workload score and ICU length of stay. To investigate associations with sex, we used logistic regression and multivariate analyses on the entire cohort as well as on two subgroups stratified by median age for menopause (up to and including 45 years and older than 45 years) and six selected diagnostic subgroups (sepsis, multiple trauma, chronic obstructive pulmonary disease, acute respiratory distress syndrome, pneumonia and cardiac arrest).

RESULTS

There was no sex difference in risk-adjusted mortality for the cohort as a whole, and there was no sex difference in risk-adjusted mortality in the group 45 years of age and younger. For the group of patients older than 45 years of age, we found a reduced risk-adjusted mortality in men admitted for cardiac arrest. For the cohort as a whole, and for those admitted with multiple trauma, male sex was associated with a higher nurse workload score and a longer ICU stay.

CONCLUSIONS

Using information derived from a large multiple ICU register database, we found that premenopausal female sex was not associated with a survival advantage following intensive care in Sweden. When the data were adjusted for age and severity of illness, we found that men used more ICU resources per admission than women did.

Positive Deviance A New Strategy for Improving Hand Hygiene Compliance

Objective.

To evaluate the effectiveness of a positive deviance strategy for the improvement of hand hygiene compliance in 2 adult step-down units.

Design.

A 9-month, controlled trial comparing the effect of positive deviance on compliance with hand hygiene.

Setting.

Two 20-bed step-down units at a tertiary care private hospital.

Methods.

The first phase of our study was a 3-month baseline period (from April to June 2008) in which hand hygiene episodes were counted by use of electronic handwashing counters. From July to September 2008 (ie, the second phase), a positive deviance strategy was implemented in the east unit; the west unit was the control unit. During the period from October to December 2008 (ie, the third phase), positive deviance was applied in both units.

Results.

During the first phase, there was no statistically significant difference between the 2 step-down units in the number of episodes of hand hygiene per 1,000 patient-days or in the incidence density of healthcare-associated infections (HAIs) per 1,000 patient-days. During the second phase, there were 62,000 hand hygiene episodes per 1,000 patient-days in the east unit and 33,570 hand hygiene episodes per 1,000 patient-days in the west unit (P < .01). The incidence density of HAIs per 1,000 patient-days was 6.5 in the east unit and 12.7 in the west unit (P = .04). During the third phase, there was no statistically significant difference in hand hygiene episodes per 1,000 patient-days (P = .16) or in incidence density of HAIs per 1,000 patient-days.

Conclusion.

A positive deviance strategy yielded a significant improvement in hand hygiene, which was associated with a decrease in the overall incidence of HAIs.

Nursing workload in intensive care unit trauma patients: analysis of associated factors

BACKGROUND

From the perspective of nurses, trauma patients in the Intensive Care Unit (ICU) demand a high degree of nursing workload due to hemodynamic instability and the severity of trauma injuries. This study aims to identify the factors related to the high nursing workload required for trauma victims admitted to the ICU.

METHODS

This is a prospective, cross-sectional study using descriptive and correlation analyses, conducted with 200 trauma patients admitted to an ICU in the city of São Paulo, Brazil. The nursing workload was measured using the Nursing Activities Score (NAS). The distribution of the NAS values into tertiles led to the identification of two research groups: medium/low workload and high workload. The Chi-square, Fisher's exact, Mann-Whitney and multiple logistic regression tests were utilized for the analyses.

FINDINGS

The majority of patients were male (82.0%) and suffered blunt trauma (94.5%), with traffic accidents (57.5%) and falls (31.0%) being prevalent. The mean age was 40.7 years (± 18.6) and the mean NAS was 71.3% (± 16.9). Patient gender, the presence of pulmonary failure, the number of injured body regions and the risk of death according to the Simplified Acute Physiology Score II were factors associated with a high degree of nursing workload in the first 24 hours following admission to the ICU.

CONCLUSION

Workload demand was higher in male patients with physiological instability and multiple severe trauma injuries who developed pulmonary failure.

Sobrecarga de trabalho da Enfermagem e incidentes e eventos adversos em pacientes internados em UTI

Estudo prospectivo, tipo coorte que visou identificar a influência da sobrecarga de trabalho da Enfermagem na ocorrência de incidentes sem lesão e eventos adversos em 399 pacientes internados em Unidades de Terapia Intensiva (UTI). Para coleta de dados, foi aplicado um questionário estruturado e feita análise de prontuários. Nessas admissões, aproximadamente 78% dos incidentes sem lesão e eventos adversos em pacientes foram relacionados à esfera da Enfermagem. Essas ocorrências foram atribuídas à sobrecarga de trabalho, aumentaram o número de dias de internação e o risco de óbito dos pacientes estudados. É fundamental que os gerentes de enfermagem atuem no processo de gestão de pessoas no âmbito hospitalar, evitando a sobrecarga de trabalho e proporcionando, consequentemente, aumento da segurança do paciente.

Nursing Activities Score and workload in the intensive care unit of a university hospital

OBJECTIVE

The nursing workload consists of the time spent by the nursing staff to perform the activities for which they are responsible, whether directly or indirectly related to patient care. The aim of this study was to evaluate the nursing workload in an adult intensive care unit at a university hospital using the Nursing Activities Score (NAS) instrument.

METHODS

A longitudinal, prospective study that involved the patients admitted to the intensive care unit of a university hospital between March and December 2008. The data were collected daily to calculate the NAS, the Acute Physiology and Chronic Health Evaluation (APACHE II), the Sequential Organ Failure Assessment (SOFA) and the Therapeutic Intervention Scoring System (TISS-28) of patients until they left the adult intensive care unit or after 90 days of hospitalization. The level of significance was set at 5%.

RESULTS

In total, 437 patients were evaluated, which resulted in an NAS of 74.4%. The type of admission, length of stay in the intensive care unit and the patients' condition when leaving the intensive care unit and hospital were variables associated with differences in the nursing workload. There was a moderate correlation between the mean NAS and APACHE II severity score (r=0.329), the mean organic dysfunction SOFA score (r=0.506) and the mean TISS-28 score (r=0.600).

CONCLUSION

We observed a high nursing workload in this study. These results can assist in planning the size of the staff required. The workload was influenced by clinical characteristics, including an increased workload required for emergency surgical patients and patients who died.

Association between trauma patients' severity and critical care nursing workload in China

The correlation between patients' severity and nursing workload for multiple trauma patients within the first 24 h of admission was explored in this study. Multiple trauma adult patients (n = 229) admitted in the emergency rescue room of a public hospital in China over a 1 year period were enrolled in this study. The worst values of the Acute Physiology and Chronic Health Evaluation-II scores and the Nursing Activity Score were collected during the first 24 h after admission. The predicted number of registered nurses was calculated for the corresponding severity groups. In the results, one-way ANOVA revealed that the Nursing Activity Score in the seven severity groups differed significantly. The total Acute Physiology and Chronic Health Evaluation-II score had a positive correlation with the Nursing Activity Score. The predicted number of registered nurses required was 0.6 for the low group, 0.7 for the moderate group, 1.0 for the severe group, and 1.1 for the extremely severe group. Patients' illness severity is an important indicator of nursing workload, especially in nurse staff allocation within the emergency department.

[Creation and validation of an instrument to identify nursing activities in pediatric wards: information for determining workload]

The aim of this study was to develop and validate an instrument for identifying nursing activities performed in a pediatric ward and to provide a basis for defining the workload of these units. The instrument was developed by selecting the activities relevant to pediatric nursing from the Nursing Intervention Classification and then submitting them to a panel of judges for validation. The panel considered the selected activities relevant and representative of pediatric nursing practice. Now that representative activities for the nursing workload have been identified, we envision new studies to verify their usefulness in practice. Determining the amount of time each activity takes to perform will help to develop a system for measuring the workloads of nursing teams in pediatric wards.

[Usage analysis of the Nursing Activities Score in two Spanish ICUS]

The aim of this study was to analyze the discourse of health managers on aspects related to delay in tuberculosis diagnosis. This was a qualitative research study, conducted with 16 Family Health Unit managers. The empirical data were obtained through semi-structured interviews. The analysis was based on the theoretical framework of the French school of discourse analysis. According to the managers' statements, the delay in tuberculosis diagnosis is related to patient and health service aspects. As for patient aspects, managers report fear, prejudice and lack of information as factors that may promote a delayed diagnosis. Regarding health service aspects, structural problems and lack of professional skills were reported. The discourse of managers should be considered to qualify tuberculosis control actions and to prevent delays in diagnosis.

An Updated Therapeutic Intervention Scoring System for Critically Ill Children Enables Nursing Workload Assessment With Insight Into Potential Untoward Events

BACKGROUND

To introduce an updated version of the original Therapeutic Intervention Scoring System (TISS) applicable to critically ill children (TISS-C). This version was designed to assess patient acuity and nursing workload (NW) and to determine a relationship between such assessment and the incidence of adverse events.

METHODS

Reviewing previous versions of TISS, an updated TISS-C was developed. Items inapplicable to pediatric critical care were eliminated; items current to critical care were added; and items still valid were edited. The point system accounts for the wide range of care provided. Random patients from a predetermined period had TISS-C scores calculated. The TISS-C scores were also calculated on patients with documented adverse events. Baseline scores were compared with scores of patients in whom adverse events had occurred. We determined the pediatric intensive care unit (PICU) NW to be the product of the TISS-C score and the patient-nurse ratio (PNR).

RESULTS

One hundred twenty-five random patients had a mean TISS-C of 14.6 ± 11.8. Patients with any adverse event (98) had a TISS-C of 19.9 ± 11.6 (P < .05). Using our PICU mean PNR of 1.4 (20 patients/14 nurses), the NW for patients with more severe events was 33.6 ± 15.9.

CONCLUSIONS

Critically ill pediatric patients are more vulnerable to experience adverse events when their derived NW values are high. It is postulated that a critical NW exists, where adverse events are more likely to occur.

Scope of nursing care in Polish intensive care units

INTRODUCTION

The TISS-28 scale, which may be used for nursing staff scheduling in ICU, does not reflect the complete scope of nursing resulting from varied cultural and organizational conditions of individual systems of health care.

AIM

The objective of the study was an attempt to provide an answer to the question what scope of nursing care provided by Polish nurses in ICU does the TISS-28 scale reflect?

MATERIAL AND METHODS

The methods of working time measurement were used in the study. For the needs of the study, 252 hours of continuous observation (day-long observation) and 3.697 time-schedule measurements were carried out.

RESULTS

The total nursing time was 4125.79 min. (68.76 hours), that is, 60.15% of the total working time of Polish nurses during the period analyzed. Based on the median test, the difference was observed on the level of χ(2) = 16945.8,P < 0.001 between the nurses' workload resulting from performance of activities qualified into the TISS-28 scale and load resulting from performance of interventions within the scopes of care not considered in this scale in Polish ICUs.

CONCLUSIONS

The original version of the TISS-28 scale does not fully reflect the workload among Polish nurses employed in ICUs.

[Patient profile and nursing workload at the nephrology unit]

Chronic kidney failure (CKF), which is frequently silent, can lead to considerable changes in the lives of patients. Depending on the stage, hospitalization and hours of nursing care are required to ensure medical and surgical treatment. The aim of this descriptive and quantitative study is to measure nursing workload at a nephrology unit based on daily application of the Nursing Activities Score (NAS) for 47 consecutive days. Patients were mostly young male adults in the chronic stage of the disease or admitted for kidney transplant. A total of 833 observations were obtained from 62 patients. The resulting NAS workload upon admission was 52%, corresponding to 12.5 hours of care per patient for 24 hours, which is similar to the workload found in intensive care units. This profile allows calculation of nursing work hours required for each patient and is a valuable tool for nursing managers when determining the number of staff members required to ensure assistance. Other studies should be conducted for clinical validation.

Nursing care time and quality indicators for adult intensive care: correlation analysis

The objective of this quantitative, correlational and descriptive study was to analyze the time the nursing staff spends to assist patients in Adult Intensive Care Units, as well as to verify its correlation with quality care indicators. The average length of time spent on care and the quality care indicators were identified by consulting management instruments the nursing head of the Unit employs. The average hours of nursing care delivered to patients remained stable, but lower than official Brazilian agencies' indications. The correlation between time of nursing care and the incidence of accidental extubation indicator indicated that it decreases with increasing nursing care delivered by nurses. The results of this investigation showed the influence of nursing care time, provided by nurses, in the outcome of care delivery.

The meaning and importance of vigilant attendance for the relatives of intensive care unit patients

AIM

To explore the meaning of vigilant attendance for relatives of critically ill patients in Greece.

BACKGROUND

A plethora of international research has identified proximity to the patient to be a major concern for relatives of critically ill patients. Greece however follows a strict visiting policy in intensive care units (ICUs) so Greek relatives spend great amounts of time just outside the ICUs.

DESIGN

This qualitative study adopted the social constructionist version of grounded theory.

METHOD

Data were collected from three ICUs in Athens through in depth interviews with 25 informants and approximately 10 h of observations outside the ICUs on 159 relatives.

FINDINGS

Vigilant attendance was one of the main coping mechanisms identified for relatives. Four subcategories were found to comprise vigilant attendance: (1) being as close as possible to feel relief, (2) being there to find out what is going on, (3) monitoring changes in the loved one and making own diagnosis and (4) interacting with the ICU professionals.

CONCLUSION

Vigilant attendance describes the way in which relatives in Greece stayed outside the ICUs. Relatives felt satisfaction from being close as the best alternative for not actually being inside the ICU and they tried to learn what was going on by alternative methods. By seeing the patients, relatives were also able to make their own diagnoses and could therefore avoid relying solely on information given to them. However, a prerequisite for successful vigilant attendance was to get on well with doctors and nurses.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Changes in visiting policies in Greece are needed to meet the needs of relatives adequately. Recommendations for changes with minimal investment of time and funding are made.

[Assessment of nursing workload in three groups of patients in a Spanish ICU using the Nursing Activities Score Scale]

The purpose of this study was to assess the nursing workload at admission to and discharge from intensive care of three groups of patients (i.e., acute coronary syndrome, acute respiratory failure, and sepsis). A prospective, descriptive study was performed over a 27-month period and included 563 patients. The workload was assessed using the Nursing Activities Score scale. Significant differences in the workload were determined on the days of admission and discharge: the workload was higher in both cases for patients with acute respiratory failure and sepsis compared with patients diagnosed with acute coronary syndrome. This difference was maintained over the first seven days of their hospital stay. From day 8 on, the difference disappeared, and a workload balance was achieved in the three groups. Good staffing requires adequate tools for measuring care needs and understanding the workload required in the groups of patients who are most frequently admitted to intensive care.

Nursing workload in the emergency department: a methodological proposal

OBJECTIVE: This study aimed to propose a methodology for identifying the nursing workload in the Emergency Department (ED). METHODS: this is methodological research, undertaken in a public general hospital in the municipality of São Paulo, Brazil, in the areas: triage, shock room, emergency room, suturing room, and medication/procedures for adult and pediatric patients rooms, using different strategies and instruments. Due to the characteristics of the data collection, distinct samples were obtained in each of the areas. RESULTS: The average daily workload, in hours, corresponded to: triage 48; shock room 30.9; emergency 170.6; observation of adult patients 293.6; observation of pediatric patients 108.7; medication/procedures in adult patients 175.5; medication/procedures in pediatric patients 60.4; and suturing 7.9. CONCLUSION: The instruments used for data collection were shown to be appropriate and made it possible to construct a methodological proposal for identification of workload of nursing professionals in E.D. in a general public hospital.

[Influence of personnel staffing on patient care and nursing in German intensive care units. Descriptive study on aspects of patient safety and stress indicators of nursing]

In this article selected results of a descriptive study on personnel staffing and patient care in German intensive care units are presented and discussed. The main focus is on comparing features of personnel staffing with indicators of the job situation and patient care. The study is based on a standardized survey of nursing managers from 535 intensive care units carried out in 2011. The results show that a low nurse-patient ratio in intensive care units has a tendency to cause higher risks in patient care and also in other stress indicator situations, such as absenteeism.

Carga de trabalho de enfermagem em unidade de recuperação pós-anestésica

OBJETIVOS: Avaliar a carga de trabalho de enfermagem em unidade de recuperação pós-anestésica e relacionar com o índice de gravidade cirúrgico, tempo de permanência, porte cirúrgico e idade. MÉTODOS: Estudo transversal conduzido em hospital universitário. A carga de trabalho foi avaliada pelo Nursing Activities Score e o índice de gravidade pelo Simplified Acute Physiology Score II aplicados na alta da unidade de recuperação. RESULTADOS: Foram incluídos 160 pacientes, idade média 57±15 anos. A carga de trabalho para 50% dos pacientes foi de 45,6 minutos a cada hora de permanência na unidade. Não houve relação entre carga de trabalho e índice de gravidade. Contudo, houve correlações positivas entre carga de trabalho, tempo de permanência e porte cirúrgico. O índice de gravidade apresentou correlação com a idade. CONCLUSÃO: A carga de trabalho de enfermagem em unidade de recuperação pós-anestésica sofre influência do tempo de permanência e do porte cirúrgico.

Validação Concorrente de Escores de Enfermagem (NEMS e TISS-28) em terapia intensiva pediátrica

OBJETIVO: Examinar a validade concorrente do escore Nine Equivalents of Nursing Manpower Use Score (NEMS) em comparação ao Therapeutic Intervention Scoring System-28 (TISS-28) em uma Unidade de Terapia Intensiva Pediátrica (UTIP). MÉTODOS: Estudo de coorte prospectivo observacional, realizado na UTIP de um hospital universitário brasileiro, no período de dois anos, com uma amostra de 816 pacientes. Foram realizadas 7.702 observações de cada um dos escores. RESULTADOS: A média da pontuação máxima do NEMS foi 26,6±9,2 e do TISS-28 21,3±8,2. Em todas as médias, o TISS-28 foi inferior ao NEMS (p<0,001). Houve uma boa correlação entre eles (r²=0,704 para todas as observações). A concordância entre o TISS-28 e o NEMS foi boa, apresentando apenas 6,2% de diferença entre os escores. CONCLUSÃO: Os resultados mostraram boa correlação e concordância entre o TISS-28 e o NEMS, permitindo validar o NEMS nessa população de pacientes pediátricos.

Nursing workload as a risk factor for healthcare associated infections in ICU: a prospective study

INTRODUCTION

Nurse understaffing is frequently hypothesized as a potential risk factor for healthcare-associated infections (HAI). This study aimed to evaluate the role of nursing workload in the occurrence of HAI, using Nursing Activities Score (NAS).

METHODS

This prospective cohort study enrolled all patients admitted to 3 Medical ICUs and one step-down unit during 3 months (2009). Patients were followed-up until HAI, discharge or death. Information was obtained from direct daily observation of medical and nursing rounds, chart review and monitoring of laboratory system. Nursing workload was determined using NAS. Non-compliance to the nurses' patient care plans (NPC) was identified. Demographic data, clinical severity, invasive procedures, hospital interventions, and the occurrence of other adverse events were also recorded. Patients who developed HAI were compared with those who did not.

RESULTS

195 patients were included and 43 (22%) developed HAI: 16 pneumonia, 12 urinary-tract, 8 bloodstream, 2 surgical site, 2 other respiratory infections and 3 other. Average NAS and average proportion of non compliance with NPC were significantly higher in HAI patients. They were also more likely to suffer other adverse events. Only excessive nursing workload (OR: 11.41; p: 0.019) and severity of patient's clinical condition (OR: 1.13; p: 0.015) remained as risk factors to HAI.

CONCLUSIONS

Excessive nursing workload was the main risk factor for HAI, when evaluated together with other invasive devices except mechanical ventilation. To our knowledge, this study is the first to evaluate prospectively the nursing workload as a potential risk factor for HAI, using NAS.

Sítios assistenciais em Unidade de Terapia Intensiva e relação do nursing activities score com a infecção hospitalar

O Sistema de Classificação de Pacientes tornou-se essencial na prática gerencial e assistencial do enfermeiro. Este estudo analisou a implantação de Sítios Assistenciais na Unidade de Terapia Intensiva Adulto como forma de organização e classificação de pacientes, bem como suas implicações na qualidade do cuidado de acordo com o Nursing Activities Score e a relação com a Infecção Hospitalar. Trata-se de um estudo quantitativo, prospectivo, descritivo e transversal. A coleta foi realizada de julho a outubro de 2010. A amostra foi constituída por 214 pacientes, a maioria do sexo masculino, de neurocirurgia e com idade média de 57 anos. O Nursing Activities Score médio foi de 71,72%. Com relação à Infecção Hospitalar antes e após a implantação, houve redução nas taxas de pneumonia, porém, a carga de trabalho de enfermagem permaneceu constante. Ficou evidenciada a importância da utilização do Nursing Activities Score como indicador e da implantação de novas formas de classificação de pacientes para melhorar a organização da assistência.

Alocação da equipe de enfermagem e ocorrência de eventos adversos/incidentes em unidade de terapia intensiva

A segurança do paciente representa um desafio para a excelência da qualidade no setor saúde. Este estudo objetivou: verificar a adequação entre a alocação da equipe de enfermagem e as horas de cuidado requeridas pelos pacientes, bem como identificar a relação entre essa alocação com eventos adversos/incidentes (EA/I). Trata-se de pesquisa observacional, descritiva e prospectiva, desenvolvida nas Unidades de Terapia Intensiva Clínicas do 4º andar e 6º andar de um Hospital Universitário, do município de São Paulo, Brasil, no período de 01/11/07 a 10/12/07, com 46 pacientes. Nas UTIs 4º andar e 6º andar, respectivamente, 43,3% e 10,3% das alocações foram inadequadas (p = 0,000). Houve diferença na frequência de EA/I nas alocações adequadas e inadequadas da equipe de enfermagem da UTI 4º andar e UTI 6º andar, p = 0,0004 e p = 0,000, respectivamente. Concluiu-se que, quanto maior a diferença entre as horas disponíveis e requeridas de cuidado nas alocações de enfermagem, menor a frequência de EA/I.

Monitoring costs in the ICU: a search for a pertinent methodology

Attempts to determine costs in the intensive care unit (ICU) were not successful until now, as they failed to detect differences of costs between patients. The methodology and/or the instruments used might be at the origin of this failure. Based on the results of the European ICUs studies and on the descriptions of the activities of care in the ICU, we gathered and analysed the relevant literature concerning the monitoring of costs in the ICU. The aim was to formulate a methodology, from an economic perspective, in which future research may be framed. A bottom-up microcosting methodology will enable to distinguish costs between patients. The resulting information will at the same time support the decision-making of top management and be ready to include in the financial system of the hospital. Nursing staff explains about 30% of the total costs. This relation remains constant irrespective of the annual nurse/patient ratio. In contrast with other scoring instruments, the nursing activities score (NAS) covers all nursing activities. (1) NAS is to be chosen for quantifying nursing activities; (2) an instrument for measuring the physician's activities is not yet available; (3) because the nursing activities have a large impact on total costs, the standardisation of the processes of care (following the system approach) will contribute to manage costs, making also reproducible the issue of quality of care; (4) the quantification of the nursing activities may be the required (proxy) input for the automated bottom-up monitoring of costs in the ICU.

Nursing workload in neurological intensive care units: cross-sectional study

BACKGROUND

Nursing workload has been associated with quality of patient care. Thus, it is important to measure nursing workload in neurological intensive care units (neuro-ICUs).

OBJECTIVE

The aims of the study were to assess nursing workload in neuro-ICUs and identify independent factors associated with nursing workload.

METHOD

This descriptive, cross-sectional study was conducted in two neuro-ICUs with 11 beds each (for a total of 22 beds) of a private general hospital in the city of São Paulo, Brazil. Data from the first 24 hours of admission to the neuro-ICUs from 100 consecutive patients were collected from the hospital database. The Nursing Activities Score (NAS) was used to assess nursing workload in the neuro-ICUs. Data were analysed using descriptive and inferential statistics and multiple linear regression analysis. Statistical significance was set at α=0.05.

RESULTS

Patients were mostly men (52.00%), had a mean age of 55.10 years, median length of ICU stay of 2 days, and survival rate of 94.00%. Fifty-nine percent of patients were transferred from the surgical ward. Mean NAS was 65.18% (standard deviation=6.63%) and the risk of mortality according to the Simplified Acute Physiology Score (SAPS II) and the Logistic Organ Dysfunction System (LODS) was 17.79% and 16.30%, respectively.

CONCLUSION

The present results are important for the effective planning and use of nursing resources according to the care needs of patients in neuro-ICUs.

[NEMS: a new predictor of mortality in the critical patient?]

Numerical scales are commonly used in intensive care units to predict hospital mortality and to assess the therapeutic effort and care that critically ill patients require. The aim of this work was to study whether the NEMS value can be used as a predictor of mortality, comparing it with the APACHE II. A prospective study in a 24 intensive care unit beds was conducted. The APACHE II and NEMS values were stratified into three levels. Demographic data and the first 24 hours values of APACHE II and NEMS scales were collected. A total of 1257 patients were included, 16.4% of whom died. 69.6% were surgical; median stay was 2 days (1-4). Median age was 66 years (50-77), 59.3% were men. The median APACHE II and NEMS for the living and the dead in the subsequent course was 10 (6-20) versus 22.5 (17.25 to 29) (p <0.001) and 24 (18-29) versus 34 (25 to 39.7) (p<0.001) respectively. The correlation between both scales was rho=0.457 (p<0.01). Logistic regression controlled for age, sex and APACHE II showed an OR of 3.1 (95% CI: 1.5-6.6) only for high NEMS, compared to the lowest level. According to the results NEMS should not be used as a predictor of mortality, although the risk of death increases by three times with high NEMS.

Nursing Activities Score e demanda de trabalho de enfermagem em terapia intensiva

OBJETIVO: Medir e caracterizar a carga de trabalho de enfermagem em Unidade de Terapia Intensiva (UTI) por meio da aplicação do Nursing Activities Score (NAS). MÉTODOS: Estudo descritivo quantitativo, retrospectivo, realizado em uma das UTIs de um Hospital Filantrópico de Teresina- PI, de setembro a outubro de 2010, com amostra de 66 pacientes. Foram realizadas 285 medidas do escore NAS. RESULTADOS: Quanto à carga de trabalho de enfermagem, foi verificada uma média do escore total do NAS de 68,1% (51,5% e 108,3%), correspondendo à porcentagem de tempo gasto pelo profissional de enfermagem na assistência direta ao paciente nas 24 horas. Houve correlação estatística entre NAS e desfecho clínico (p= 0,001). Já entre NAS e tempo de internação (p= 0,073) e NAS e idade (p=0,952), não houve significância estatística. CONCLUSÃO: Os resultados mostraram que os pacientes apresentaram elevada necessidade de cuidados, refletida pela média elevada do NAS.

Carga de trabalho de enfermagem em Unidade de Terapia Intensiva de um hospital de ensino

OBJETIVO: Avaliar a carga de trabalho de enfermagem em uma Unidade de Terapia Intensiva (UTI) - adulto e descrever o perfil dos pacientes, nela, internados. MÉTODOS: estudo descritivo com o uso do Nursing Activities Score - NAS durante 33 dias em uma UTI com capacidade para 18 leitos. RESULTADOS: Foram 574 observações, obtidas do registro de 107 pacientes e a média da pontuação do NAS foi de 62,2%. CONCLUSÃO: O NAS constitui-se em um importante instrumento para mensurar a carga de trabalho de enfermagem em UTI, uma vez que contempla diversas atividades de enfermagem realizadas no dia a dia da assistência. Ressalta-se a importância de tornar sua aplicação parte do cotidiano do enfermeiro.

Risk factors for prolonged stay in cardiac surgery intensive care units

AIMS AND OBJECTIVES

To identify the factors that might affect the length of stay in the intensive care unit (ICU-LOS) among cardiac surgery patients.

BACKGROUND

ICU-LOS forms an important factor for assessing the effectiveness of the provided nursing care. A number of factors can be accused for increasing patient hospitalization. The nursing workload (NWL), among others, was found to play a significant role as it is closely associated with the quality of care.

DESIGN

An observational cohort study among 313 consecutive patients who were admitted to the cardiac surgery intensive care unit of a general, tertiary hospital of Athens, Greece from November 2008 to November 2009.

METHODS

Data collection was performed by using a short questionnaire (for basic demographic information) and two instruments, the Nursing Activities Score (NAS) and the logistic EuroSCORE, for assessing the NWL and the perioperative risk for each patient respectively.

RESULTS

ICU-LOS of more than 2 days increased with age and was more common among females (p < 0.001 and p = 0.02, respectively). Multivariate logistic regression analysis revealed a positive association between increased perioperative risk and the increased ICU-LOS [odd ratio (OR) 1.9, 95% confidence interval (CI) 1.0-3.5, p = 0.04], while patients with a first day NAS of more than 61.6% had an almost 5.2 times greater probability to stay in the cardiac surgery unit for more than 2 days (OR 5.2, 95% CI 3.0-8.8, p < 0.001).

CONCLUSIONS

Increased level of NWL and patient perioperative risk are closely associated with increased ICU-LOS.

RELEVANCE TO CLINICAL PRACTICE

The correlation between patient perioperative risk and ICU-LOS encourages the early identification of high-risk patients for prolonged hospitalization. Furthermore, the relationship between NWL and ICU-LOS allows the early identification of these patients with the use of an independent nursing tool.

Sistema NAS: Nursing Activities Score em tecnologia móvel

Este estudo objetivou apresentar a estrutura informatizada que viabiliza a utilização do Nursing Activities Score (NAS) em tecnologia móvel. Trata-se de um projeto de desenvolvimento de produção tecnológica baseado na engenharia de software, fundamentada na teoria do ciclo de vida de desenvolvimento de sistema. O Sistema NAS foi construído em dois módulos: módulo de pesquisa, cujo acesso é realizado através de computador pessoal (PC) e módulo de coleta de dados, acessado por meio de dispositivo móvel (smartphone). O Sistema NAS foi construído de modo a permitir que outros formulários, além do instrumento NAS, sejam incluídos futuramente. Assim, entende-se que o desenvolvimento do Sistema NAS permitirá a aproximação entre os enfermeiros e a tecnologia móvel facilitando o acesso imediato aos dados do instrumento referentes aos pacientes, auxiliando na tomada de decisão e na adequação do quantitativo de pessoal de enfermagem para prestação da assistência.

Cost of nursing staffing adequacy in a neonatal unit

The objectives of this descriptive, quantitative study were: to identify the mean nursing care time provided and required by newborns (NB) hospitalized at the Neonatal Unit of the University of São Paulo University Hospital; to calculate the cost of the mean nursing care time provided and required, by NB; to assess the cost of the nursing staffing adequacy required to assist the NB. The mean nursing care times, provided by the nursing staff and required by NBs, were calculated using equations available in the literature and by applying the Nursing Activities Score. The costs of the mean nursing care times and to make nursing staffing adequate were calculated based on the hourly cost of nurses and nursing technicians. The financial impact of nursing staffing adequacy accounted for a 30% increase over the cost of the current situation.

Carga de trabalho de enfermagem em unidade de terapia intensiva de cardiologia e fatores clínicos associados

O estudo objetivou identificar a carga de trabalho de enfermagem em unidade de Terapia Intensiva de Cardiologia e verificar a associação dessa variável com características demográficas e clínicas dos pacientes. A amostra foi de 100 pacientes internados no período de agosto a setembro de 2006, na Unidade de Terapia Intensiva Cardiológica de um hospital privado, do Município de São Paulo. O Nursing Activities Score, o Symplified Acute Physiologic ScoreII e o Logistic Organ Disfunction System foram utilizados para medir a carga de trabalho de enfermagem, a gravidade e a disfunção orgânica, respectivamente. A carga de trabalho de enfermagem foi de 66,60%, equivalente a 5,30 horas de trabalho, em um turno de oito horas. À exceção do tempo de permanência na Unidade de Terapia Intensiva, que apresentou moderada correlação com a carga de trabalho, não houve associação com as demais variáveis analisadas. Recomenda-se a ampliação da amostra para conclusões generalizáveis.

MEASURING WORKLOAD OF ICU NURSES WITH A QUESTIONNAIRE SURVEY: THE NASA TASK LOAD INDEX (TLX)

High workload of nurses in Intensive Care Units (ICUs) has been identified as a major patient safety and worker stress problem. However, relative little attention has been dedicated to the measurement of workload in healthcare. The objectives of this study are to describe and examine several methods to measure workload of ICU nurses. We then focus on the measurement of ICU nurses' workload using a subjective rating instrument: the NASA TLX.We conducted secondary data analysis on data from two, multi-side, cross-sectional questionnaire studies to examine several instruments to measure ICU nurses' workload. The combined database contains the data from 757 ICU nurses in 8 hospitals and 21 ICUs.Results show that the different methods to measure workload of ICU nurses, such as patient-based and operator-based workload, are only moderately correlated, or not correlated at all. Results show further that among the operator-based instruments, the NASA TLX is the most reliable and valid questionnaire to measure workload and that NASA TLX can be used in a healthcare setting. Managers of hospitals and ICUs can benefit from the results of this research as it provides benchmark data on workload experienced by nurses in a variety of ICUs.

Nursing workload in an inpatient unit

This study evaluated the nursing workload in an inpatient unit of a university hospital. This descriptive study applied the Nursing Activities Score (NAS) over the course of 30 consecutive days. A total of 1,080 observations were obtained from the medical files of 156 patients. The average scored obtained in the NAS instrument was 47.31%. Considering that each single NAS score corresponds to 0.24 hours, an average of 11.35 hours of nursing care was required. This amount of hours correspond to the profile of inpatients demanding semi-intensive and intensive care, suggesting that the NAS can be used to evaluate the workload of the nursing staff in this unit.